The ABC’s of primary and secondary cardiovascular disease prevention are not complete without D (diet and weight management) and certainly without E (exercise) (1). Although coming in last in the helpful mnemonic, exercise certainly is not the least important. The benefits of increased exercise and physical activity are profound and range well beyond cardiovascular disease and weight management to include the prevention of diabetes, cancer, hypertension, depression, and osteoporosis (2). However, the time allowed for such discussions during regular outpatient visits are vastly insufficient and horrifyingly disproportionate to the magnitude of the problem that inactivity has bestowed on disease risk (3). Although many physicians lost count long ago of the number of times they have explained that they cannot call their patients daily to deliver personal motivation or be at their patients’ side to remind them to take the stairs in lieu of the elevator, today we have multiple options to help us do just that. Telephone calls are heading the way of the telegraph in that text messages, e-mail, Instagram, and Twitter have become preferred modes of communications. And, with most patients now having supercomputers literally in their pockets, we have, for the first time, the ability to deliver personalized, situationally appropriate motivational reminders that can be both dynamic and automated. As such, the number of wellness-related smartphone applications has exploded, and wearable activity monitors are seemingly more popular as holiday gifts than was Tickle Me Elmo (4). For many consumers, it is their interest in wellness and disease prevention that provides their first foray into mobile health (mHealth) via dietary applications and especially activity trackers. But, just as some individuals, more than 100 years ago, considered early pedometers as “…little better than an ingenious toy,” there remains appropriate skepticism to fully embracing mHealth technologies as the panacea for driving behavior changes such as meaningfully increasing daily activity in a sustainable manner (5).

In this issue of the Journal, Ganesan et al. (6) report promising results from the Stepathlon Cardiovascular Health Study. By providing nearly 70,000 participants with an objective means of activity tracking, in their case a traditional, low-cost pedometer, in addition to access to an interactive smartphone or web-based application, they showed consistent and reproducible improvements in step count, exercise days, sitting duration, and weight during the course of their 14-week program. Although this methodology has been appreciated and reported by others, we congratulate this group for ambitiously yet successfully translating this approach to a large, multinational population for 3 successive years. Although these results are encouraging, there are several questions that remain. Primarily, can this approach achieve sustained, long-term changes in physical activity that would subsequently lead to improved health and quality of life for all participants?

The immediate successes and positive short-term outcomes (on average, 3 months) for participants using activity monitors and wellness applications are well appreciated (7). But, we are still lacking data to support sustained improvements that would carry beyond several months. Maybe it is telling that in the present study, on a year over year basis, the pre-program step count did not appear to change perceptibly. For the investigators, it might be especially interesting to explore in greater detail the workplaces and especially individuals engaged in consecutive years. Perhaps the field’s overall lack of long-term data is secondary to inadequate research funding for such studies or possibly pressure from commercial entities to generate only data supportive of the use of their technologies. With every incentive to remain in the wellness space rather than potentially traverse the U.S. Food and Drug Administration’s maze for approved disease management, there is little motivation for technology developers to sponsor meaningful, long-term outcome trials. However, as anyone who has attempted a sustained physical activity or weight loss goal can appreciate first hand, these efforts are incredibly difficult and not traditionally successful, and there are endless volumes of data supporting this. What remains elusive, however, are the key factors that are ultimately responsible for the individual successes or failures in respect to these efforts and areas that will require a uniquely personalized incentivizing targeted to a specific individual. In this study alone, the rate of attrition was significant, a little below 50%, and although this percentage is historically “acceptable” for trials of this nature, we remain at a loss in understanding the factors related to this. For lasting change, 1 size certainly does not fit all.

Another important consideration in interpreting the results of the Stepthalon intervention is whether it represents the true potential of a 21st century mHealth intervention. mHealth was born out of parallel advances in computing power and mobile connectivity and brings with it the hope and promise of a more personalized, democratized, and efficient approach to health and medicine (8). Here, the investigators employed a noninteractive pedometer that was supplemented with online (not necessarily mobile) data entry and contest updates in addition to daily motivational and educational e-mails, although apparently not personalized to the participant. The importance of the connectivity between the participants, gamification of this program, and the details pertaining to daily e-mails and motivational messages should not be overlooked, as these have been reported to be the major drivers in the success of prior studies (9,10). However, we are presented with few particulars of these in this current study. Enrolling tens of thousands of international participants in a pedometer and web-based activity tracking study in the pre-ResearchKit era, especially in a low- to moderate-income global population, is noteworthy. And, although using daily e-mails and online tracking is likely beneficial, there are aspects of a more comprehensive mHealth intervention, such as connected devices and automated, personalized, targeted, and motivational text messages, that would have made this still laudable study that much more meaningful in the era of mHealth.

The opportunities to study a fully integrated mHealth approach to sustainably improving physical activity with the goal of chronic disease prevention and management are rich. However, despite how critically important the need is, it remains unknown how to best achieve true, life-long behavior change. Nonetheless, there are several key components of mHealth that will be required, in particular the ability to provide a personalized approach that bolsters self-control and self-efficacy as well as allows for motivational reinforcement whenever and wherever needed. Rather than relying on participants to enter and self-report data for steps taken, time spent sitting, weight, or even blood pressure and heart rate, a nonobtrusive, passive sensor that seamlessly integrates with electronic documentation is vital and is now possible. By having a continuous assessment of steps taken over time and eliminating the need for participants to manually log data entries on a daily or weekly basis, investigators will better understand how and when participants increased their physical activity and can therefore allow for reinforcement messaging and goal setting that best fits that individual. Although their step counts may be similar, someone who walked 25 extra minutes several times a week is not the same as a person who does high-intensity interval training workouts on the weekends. Additionally, 1 of the most attractive components of the mHealth movement is the ability to fully personalize and automate interactions, even through an avatar of the user’s choosing, allowing for a dynamic and interactive experience.

The year after year success of Stepathlon, albeit in the short term, is an important benchmark for what is possible through a well-designed, workplace-based wellness program. But, this study only scratches the surface of what is possible in the continuously expanding era of digital health. Although efforts to use mHealth technologies to better understand individual practices and personalized interventions that promote improved physical activity are long overdue, we believe strongly that the integration of passive sensing modalities, multidirectional communication capabilities, and personal customization will help move mHealth from being considered gadgets, gizmos, and ingenious toys to being integral partners with ourselves and caregivers in healthspan and disease management.

Footnotes

↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.

Drs. Muse and Steinhubl are supported by the National Institutes of Health/National Center for Advancing Translational Sciences grant UL1TR001114. Dr. Steinhubl is supported by a grant from the Qualcomm Foundation; has served as a medical advisor for Agile Edge Technologies, Airstrip Technologies, BridgeCrest Medical, DynoSense, FocusMotion, and PhysIQ; and serves on the board of directors of Nano Mobile Healthcare, Inc.

American College of Cardiology Foundation

References

(2013) A clinician’s guide to the ABCs of cardiovascular disease prevention: the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and American College of Cardiology Cardiosource Approach to the Million Hearts Initiative. Clin Cardiol36:383–393.

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